- Assists referred patients through the healthcare system and community by activating as a patient advocate and navigator.
- Participates in Primary Care Provider (PCP) patient care meetings and hospital rounding as necessary to meet the patient needs as well as contributes to the quality initiatives and collection of data associated with program.
- Manages the stroke and trauma registries.
- Supports patient self-management of disease with education, community resource support, and motivational interviewing.
- Assures home monitoring and patient knowledge that is consistent with treatment plan.
- Coordinates continuity of patient care with internal and external healthcare providers.
- Coordinates continuity of patient care with patients and families following hospital admission, discharge, follow up calls and ER visits in conjunction with the Transitional Care Management (TCM) program.
- Conducts home visits as indicated to monitor patient progress and assess needs.
- Manages high risk patient care, including management of patients with multiple co-morbidities or high risk for readmission to a hospital setting.
- Conducts comprehensive, preventive screening for patients and/or assists all support staff in daily patient interactions a needed.
- Promotes clear communication amongst a care team and treating clinicians by ensuring awareness regarding patient care plans.
- Facilitates patient medication management based upon medication reconciliation process.
- Participates on a team for data collection, health outcomes reporting, and clinical audits.
- Evaluates clinical care, utilization of resources, and development of new clinical tools, forms, and procedures.
- Assists in the development of plan of care in collaboration with the health care team.
- Demonstrates System Values in performance and behavior.
- Complies with System policies and procedures.
- Other duties may be assigned.
- Self-disciplined, energetic, passionate, and innovative.
- A team player that can follow a system and protocol to achieve a common goal.
- Highly organized and well-developed oral and written communication skills.
- Demonstrates sound judgment, decision-making and problem-solving skills.
- Able to maintain confidentiality with all aspects of information in accordance with practice, State and Federal regulations.
- Confidence to communicate and outreach to other community health care organizations and is aware of community resources.
- Bilingual (English/Spanish) preferred.
- Care Coordination experience preferred.
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Neuro Trauma Care Coordinator - Truckee, United States - Tahoe Forest Health System
Description
Bargaining Unit: EAPRate of Pay: $63.57/hour + DOE
Summary
The Neuro Trauma Care Coordinator (NTCC) is responsible for facilitating healthcare and community services for care coordination patients with neurological or trauma diagnoses. The NTCC will assess the patient's medical, psych-social and community needs and coordinate resources, advocate and provide self-management education. Each patient will have the development of a patient-centered plan of care specific to their needs with self-management goals and referrals to both internal and external resources.
Essential Duties and Responsibilities
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Supervisory Responsibilities
No supervisory responsibilities.
Minimum Education/Experience
Certificate of completion from college or vocational school Graduate of an accredited school of nursing as a Registered Nurse.
2-3 years relevant experience
Required Licenses/Certifications
California Registered Nurse (RN) - Upon hire
Basic Life Support (BLS) for Upon hire Healthcare Providers BLS: Employee will be enrolled in the Resuscitation Quality Improvement (RQI) Basic Life Support (BLS) Entry or Prep Curriculum (depending on their previous BLS certification). - Within 3 months of hire into job
Valid Driver's License in good standing - Upon hire
Nevada Registered Nurse (RN) - Upon hire
Other Experience/Qualifications